=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528655024
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SYNERGY ORTHOPEDIC SPECIALISTS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/30/2020
-----------------------------------------------------
Last Update Date | 12/23/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8388 PARKWAY DR
-----------------------------------------------------
City | LA MESA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91942-2893
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-797-1190
-----------------------------------------------------
Fax | 619-303-3206
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4445 EASTGATE MALL STE 105
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92121-1979
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-412-6080
-----------------------------------------------------
Fax | 858-412-6376
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING SPECIALIST
-----------------------------------------------------
Name | MEGHAN THOMAS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 858-412-6080
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------